Healthcare Provider Details

I. General information

NPI: 1376407288
Provider Name (Legal Business Name): NINA'S LEGACY HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5435 FOREST DR
LAKE PARK GA
31636-3326
US

IV. Provider business mailing address

5435 FOREST DR
LAKE PARK GA
31636-3326
US

V. Phone/Fax

Practice location:
  • Phone: 229-516-2503
  • Fax:
Mailing address:
  • Phone: 229-516-2503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: AGNES HINES
Title or Position: OWNER
Credential:
Phone: 229-516-2503